Trichophytic closure just over hyped?

[Jeffrey Epstein MD, FACS]

The trichophytic closure, despite what a number of surgeons claim to give the very best result, is NOT the gold standard, I am very sorry to say. Like Dr. Lindsey (I believe like me a facial plastic surgeon who was trained in trichophytic closure techniques in residency and fellowship- in my case, I have been using the trichophytic closure technique for over 18 years), I have seen more than 100 trichophytic closures over the past 2 years, done by other (very respected) surgeons, and the bottom line is- sometimes they come out very nice, but other times they do not. This variability is largely the result of how much widening of the scar there is, which is in no way related to the trichophytic closure- and in fact, it has been suggested that in donor site closures under tension, the trichophytic closure technique not be used for it does, even just a little bit, remove a bit of skin edge and therefore can increase donor site closure tension. A few other problems with the trichophytic closure technique- in patients with thick hairs, there can be some cyst formation. Also, there can be some "clumping" of the hairs- essentially little patches of 2 to 4 hairs that grow thru the scar, rather than a smooth diffuse growth.

 

Now anyone can say I am wrong, for, after all, they have seen many photos of trichophytic closures and they look great. In fact, if you wish to see literally hundreds of excellent donor site results with trichophytic closures (what I call the HITS technique- hair induction through the scar) you can go to my website www.foundhair.com.

However, the reality is, that in some patients the results of the trichophytic closure is not any better than if the standard closure was used. When excellent plastic surgery closure techniques are used, the result of the donor site scar can be outstanding, although there is some degree of variability to results.

 

Jeffrey Epstein, MD, FACS

Miami and NYC

[thanatopsis_awry]

Interesting that Dr. Epstein mentions cyst formation for patients with thick hair....I'm quite certain this has happened with me, though until now I was never really sure what was up.....

[mmhce]

in patients with thick hairs, there can be some cyst formation

 

Like thanotopsis_awry, I too have thick hairs and will have to note this.

 

thanatopsis_awry,

 

How did you deal with the cysts? Did you take medication? Did it naturally go away?

 

Thanks.

[mmhce]

However, the reality is, that in some patients the results of the trichophytic closure is not any better than if the standard closure was used.

 

 

what is the standard closure?

[Dewayne]

The difference in my scar now, after the Trichophytic closure, versus the 1991 closure I got is big. I cannot express how much better and undetectable it is now.

 

If anyone would like to drive to Atlanta and try to find my scar now, I'll buy your lunch if you can!

 

Not pimping a particular doc, because I'm sure some others can do the same but I'm thrilled with the looks of the back of my head. It appears hairs have grown through and that's what's making it undetectable.

[Dr. William Lindsey]

Although I read Dr. Epstein's input quickly as I am between patients, I think he and I are in agreement that scarring results are variable.

 

I for one think that it is 50% patient stretchability and following instructions and 50% doctor doing a tension free 2 layer closure. There maybe a few other percent variables in there but a good closure, whether tricho or not, and a compliant patient, make all the difference.

 

Dr. Lindsey McLean VA

[MrJobi]

Well I have had both closures and let me tell you I think the T closure is much better! Nothing is 100% but personally I noticed a big difference regarding how low I could clip my hair without seeing the scar

 

At the end of the day , thats what it is all about!

[Dr. Bernardino Arocha]

Both Drs. Lindsey and Epstein make valid points about trichophytic closures. I agree, and have written about this in prior blogs, the two-layer closure is pivotal in minimizing surface tension, hence rendering finer scars. It takes a scar 6-12 months to mature, if tension is applied before the scar matures then it is subject to widen. The deep layer loses strength rapidly after a few weeks so minimizing activities that weight or pull on the neck are important until the scar has matured. Usually, I reserve the tricophytic closure for the last procedure, since the yield may be decreased in future surgeries because of distortion of the follicular alignment along the scar.

[thanatopsis_awry]

mmche,

 

I waited too long w/o treatment (warm compresses and an anti-bacterial), and actually took a med for a week to help knock it out, which did a lot of good, and with warm compresses and a bit of time it all got better!

[Dr. William Lindsey]

Dr. Arocha makes some good points about scar maturation.

 

I have a hard enough time getting guys to not stretch the scalp for the first week that I am sure that 90% of my patients would not refrain from stretching the neck/scalp skin posteriorly for any length of time after suture removal no matter what the implications are.

 

So we plan that people will just live their lives after suture removal. If I can counsel them not to do crunches or arch when bench pressing, I feel that I may have a chance with them listening to me.

 

 

I recall vividly a man, a bench press record holder actually, that I worked with in 04. We did hair, and 3 days later we did his eyelids (cosmetic surgery). I really go over no strenous activity including sex after eyelid surgery for a week, as bleeding in the eye socket can cause blindness. Well he calls me 3 days after the eyelids with one eye swolen shut and the other bleeding....he had gone to the gym!

 

Everything turned out ok, but just goes to show that if I can get people to listen for a week I am fortunate.

 

Dr. Lindsey McLean VA

[Dr. Mohammad Humayun Mohma]

Dear Friends

 

Since 2005 June, I strated to use tricophytic scar closure technique. Its a standard lower edge, 1 mm wide and about a mm deep I guess as I have never measured.

I only do 1 layer closure. There are mainly 4 to 5 variables in doing a good tricophytic closure or fr that matter any closure.

 

1) Patient skin and dermal tissue reaction, some just stretch no matter what you do. They are pretty rare I guess about 1 % or so.

 

2) Surgeons technique of closing it well. I must say that is one very very important factor in producing good or bad result. I trained one surgeon over last 18 months and he still could not master the technique, and ever since he ran away without any notice I am still dealing with his bad scars and have revised about 12 of them.

 

3) FLEXIBILITY OF THE SCALP in my openion is a very imporatnt factor that can predict the outcome to a great extent. I have addressed this issue qite a few times at ISHRS and Orlando Live Surgery workshop and also at ESHRS forum. In my openion the mobility should be 5 mm over lap of the two edges. This give a very good result.

 

4) Yes 2 layers do make a difference but if done properly and not try to excise bigger strip just to give a bigger number of grafts then one layer of prolene is as good as two or three layers.

( I get quite a few clients after the Muslim Haj season, cause they need to shave off the scalp there and generally the quality of the scars that I have managed to produce recently with exception of about 10% patients, they are minimally noticeable.)

 

YES if done properly the hair do grow out of the scar...........

[Maxxy]

2) Surgeons technique of closing it well. I must say that is one very very important factor in producing good or bad result. I trained one surgeon over last 18 months and he still could not master the technique, and ever since he ran away without any notice I am still dealing with his bad scars and have revised about 12 of them.

 

Dr M Humayun Mohmand, are you saying you were training a surgeon for 18 months in your clinic who couldn't master the technique and then ran off leaving your practice with patients who had bad scars as a result of this surgeon (which you are repairing)?

 

Correct me if I'm wrong.

[mmhce]

generally the quality of the scars that I have managed to produce recently with exception of about 10% patients, they are minimally noticeable

 

 

Dr M Humayun Mohmand,

 

Are these statistics for all HT patients or are they representative of your patients only?

 

Thanks in advance for the clarification.

[Dr. William Lindsey]

Each doctor has his own experiences and what works in their own hands.

 

For me, that deep layer makes all of the difference whether the wound is on the face or the scalp or the extremities.

 

Dr. Lindsey McLean VA

[Dr. Mohammad Humayun Mohma]

I agree with Dr Lindsy

Each doctor ha his own technique and as far as the results are there the method does not make much of the difference.

There is more than one way of skinning a cat.

 

YES the Doctor whom I trained ran away(without any notice) have opened a linic for himself few blocks from my clinic. I have to deal with the scars and problems that are the teething problem of any new trainee but then we as teachers are use to such pupils. c'est la vie.

 

As I gave the patients my word so I am there to rectify their problem for no added charges, thats what I think I should have done anyway.

 

Regarding the statistics, YES it my personal and a rough guess. I do on an average of 50 to 70 surgeries per month and every two months I come accross a patient who complain so I guess that should be about 10%.....

 

But I am pretty sure most of the doctors would have more or less the same

[Maxxy]

Dr M Humayun Mohmand,

 

YES the Doctor whom I trained ran away(without any notice) have opened a linic for himself few blocks from my clinic. I have to deal with the scars and problems that are the teething problem of any new trainee but then we as teachers are use to such pupils. c'est la vie.

 

Surely this cannot be the case? Doctors allowing their trainees to keep hacking away at patients heads until they get it right?

 

 

 

Surgeons technique of closing it well. I must say that is one very very important factor in producing good or bad result. I trained one surgeon over last 18 months and he still could not master the technique, and ever since he ran away without any notice I am still dealing with his bad scars and have revised about 12 of them.

 

So, you allowed your trainee to try and perform a scar closure technique for 18 months, knowing that he hadn't mastered the technique and not only had he not mastered it but he screwed them up so bad that 12 to date have needed you to revise the bad scar.

 

This you say is normal practise and:

are the teething problem of any new trainee?

 

Well I'm sorry, and I don't care who disagrees with me - that is a bloody disgrace. If I was one of the guys with bad scars left by your trainee, I'd hold you personally responable. You allowed him to perform these closures knowing that:

 

over last 18 months and he still could not master the technique

 

I hope some of the badly scarred patients that suffered at the hands of you and your trainee read this, and come looking for you.

 

Come on, 12 so far with bad scars and you brush it off as teething problems, utterly unacceptable.

 

 

and ever since he ran away without any notice I am still dealing with his bad scars and have revised about 12 of them

 

What is meant by the above quote? If he hadn't have ran off, you would have left him to deal with the bad scars he produced?

[latinlotus]

Maaxy: great points.

 

That is why, non only you should pick a good doctor, but also you need to ensure that he is actually working on you. That is why i picked a doctor who is a control freak, and who minimize the delegation to his techs/doctor trainee as much as possible.

 

I would even advise to avoid all doctors who perform more than one surgery a day (excluding minor repairs or small HT sessions)

[mmhce]

Dr M Humayun Mohmand,

 

Maxxy is sharp and, perhaps also, your English may not be as good as ours. You may need to choose your words carefully, and defend your statements.

 

Thanks for your clarification on your personal observed statistics.

[Bill - Seemiller]

Dr. Mohmand,

 

Can you please clarify the above statements Maxxy is concerned about?

 

I think the concern here lies in whether or not your trainee produced the poor scars at your clinic and under your supervision or is now producing poor scars from his own clinic.

 

If he was still your trainee at the time, in my opinion, it should have bgeen your responsibility to directly ensure all patients that leave your clinic receive optimal closure, whether performed by you or your trainee.

 

If now that your trainee has his own practice is producing poor scars, than this is out of your control.

 

Can you please clarify this for us?

 

Bill

[thanatopsis_awry]

Wow, good call(s) people....I quickly assumed it was a language-slip-up when I first read the thread....but after combing through in detail, like Maxxy and others have done....Hopefully, that is the case though, for the sake of the patient's who got botched HTs when it could have been avoided.....

[Dr. Mohammad Humayun Mohma]

Thats a very fair concern of Maxxy

 

Well, as you must be knowing that it takes about few months before one can see the impact of a surgery on a scar.

 

Now let me answer your concerns one by one.

 

Ofcourse it is the case, he did left my practise one fine day and by the way there are loads of examples like that even in USA. That is why I said Cest la vie. Now, comming to the scar point......No doctors/pupils are not left on their own, they are trained over the period of time and every time you see a case or two which is not right you tell him how to improve.

This is how learned, but my journey was not as difficult cause i was trained Plastic surgeon before I strated to do hair transplant. but I am sure all those big names you would put your head before had a learning curve.

 

your second question.

 

YES i train my trainees for as long as necessary unless i feel that they are very close to what I am doing or the international standard of good results are. Mind you we are still learning and the learning curve never ends. With respect to that the pupil are not trained in 18 months, well what can I say, you can take a horse to a water but you cant make him drink, in some cases it takes a bit longer but it does reach there, having said that there are doctors out there who are well reputed and from my standard the scars they are producing is not as good a i think it should be and even some of my scars are far then perfect.

 

Well You are absolutely right about holding me responsible, I am responsible and that is why I am correcting the scar for no extra charge.

Mind you, I used the term he has not mastered the technique, it takes a while to become proficient, and may be I have set a very high standard for scars, that even I fail to achieve them in about 10% of my cases.

So its not as bloody disgrace as you are trying to potray it.

 

My patients know this that I am where the bug stops and YES if there is any problem they do come back to me and I welcome them and address their issues. Thats How I have build a practise where we do about 4 to 5 surgeries a day.

 

12 scars as bad sars is a teething problem, yes it would e a disgrace if the numbers would be in hundreds, but then every ones only learns the hard way, there are no simulators to learn how to stitch the scar.....this is how surgery in real world is learned.

 

Is he hadnt ran off, I would have tought him how he should have done and what mistakes he did.

 

The problem with tricophytic scar is that you need to know how much of the edge needs to be trimmed, a bit more and the hair wont grow throug the scars.

 

let me send you some of my results with the initial stages and then later ones as well.

 

Hope that would have answer your concern.

 

You all are more than welcome to ask anything more, I am here to stand my grounds and will try to improve the written english, but the best way to express my self is through my results........

 

Please forgive my gramatical and spelling mistakes.......or atleast ignore them...

[Maxxy]

Could I just point that out I did not just write the post attacking Dr M Humayun Mohmand, I also thought this may have been a language barrier concern. You will notice on page two that I wrote the following to Dr. Mohmand, in regards to his first post in this thread:

 

 

Dr M Humayun Mohmand, are you saying you were training a surgeon for 18 months in your clinic who couldn't master the technique and then ran off leaving your practice with patients who had bad scars as a result of this surgeon (which you are repairing)?

 

Correct me if I'm wrong.

 

Which is what he stated in the first post on this thread, but before I posted my concerns I wanted to make sure I understood what he was saying. In response, Dr M Humayun Mohmand wrote:

 

 

YES the Doctor whom I trained ran away(without any notice) have opened a clinic for himself few blocks from my clinic. I have to deal with the scars and problems that are the teething problem of any new trainee but then we as teachers are use to such pupils. c'est la vie.

 

This clarifies what he said was not just bad English.

 

Now, lets not get confused - the bad closures did happen at the hands of his trainee and Dr M Humayun Mohmand, this I am sure of.

 

Now, did it happen with Dr M Humayun Mohmand allowing this trainee perform the closures knowing he couldn't do a good job? I personally believe this is the case.

 

 

No doctors/pupils are not left on their own, they are trained over the period of time and every time you see a case or two which is not right you tell him how to improve.

This is how learned, but my journey was not as difficult cause i was trained Plastic surgeon before I strated to do hair transplant. but I am sure all those big names you would put your head before had a learning curve.

 

 

It is not one or two occasions that this trainee made a mistake, it is at least 12 so far which have required scar revisions. If these closures were under your supervision you should have been able to spot the closures were not going correctly and took over. These are not small, "school boy" errors which needed a word from you to your trainee on how to improve.. these are 12 so far that were bad enough to justify revisions, the fact that you say "so far" also concerns me, that statement suggests you may expect more - though, that may just be your English.

 

 

Well You are absolutely right about holding me responsible, I am responsible and that is why I am correcting the scar for no extra charge.

 

This is misguided, it should not have happened in the first place, you say free of charge as if you should be praised for being so fair - this is the absolute minimum that should be done.

 

 

Mind you, I used the term he has not mastered the technique, it takes a while to become proficient, and may be I have set a very high standard for scars, that even I fail to achieve them in about 10% of my cases.

So its not as bloody disgrace as you are trying to potray it.

 

It is a damn disgrace. Don't try to brush this off as "your" high standards not being met, these scars were not simply due to you having high standards which weren't met, these were scars that patients had major concerns about, which you agreed to the extent that you have revised 12 of them. Also the above would mean you are revising 10 scars in every 100 patients you treat, if this is the case perhaps it is you who needs more training. As you stated, you treat 5 patients per day - that's a lot of scars that don't meet your standards (if you perform 5 surgeries per day and let's say you are open 5 days per week, then that's 10 patients every month with scars that don't meet your "high" standards).

 

 

12 scars as bad sars is a teething problem, yes it would e a disgrace if the numbers would be in hundreds, but then every ones only learns the hard way, there are no simulators to learn how to stitch the scar.....this is how surgery in real world is learned.

 

You are really annoying me, these are not 12 scars that have turned out bad because anything the patient has done they are a direct result of yourself and your trainee. Referring to them as "teething problems" is insulting to me, so god knows how it comes across the the guys who were actually affected. Your trainee hasn't learned the hard way, your patients have, and it is a disgrace. I do not know how doctors learn to perform closures but if your trainee could not get it right you should have had him watch you longer and had him practise on animal or some other type of skin before letting him perform on patients again.

 

 

Is he hadnt ran off, I would have tought him how he should have done and what mistakes he did.

 

This should have been done in the first place, not after the fact. The above statement suggest to me that you were not present during every closure, or you would have been showing him how to do it right at the time.

 

I have given thought to your English difficulties but I don't believe that is the problem here.

 

I would also like to apologise to everyone for this thread going off-track but I believe these concerns need to be pointed out.

[thanatopsis_awry]

Superb analysis, Maxxy!

 

I honestly don't think Mohmand as a "bad" guy; and I think he has skill and a desire to get better. However, I believe there is a glaring discrepancy in standards -- across the board -- between Mohmand and his beliefs on running his practice, and what much of this community expects. And this discrepancy continues to show itself from time to time.

 

As with the issues that have surfaced in the past, I hope that at the very least Dr. Mohmand corrects and explains that which needs improving.

[Bill - Seemiller]

Dr. Mohmand,

 

I can understand the concerns posed by this community since ultimately, the leading surgeon is responsible for everyone under their supervision. This includes trainees, technicians, etc.

 

I recognize however, that sometimes problems aren't found immediately. However, surgeons should do everything in their power to find and remediate problems as soon as possible for the sake of their patients.

 

Did you observe every wound closure performed by this trainee? If so, how/why did the patient leave without an optimal closure? If not, why would you let the trainee perform the closure technique by his or herself?

 

Since the less than optimal scars were created under your direct supervision of this trainee, can you please tell us what you have learned from this and how you have changed your practice to prevent this from happening again?

 

The answer to the above question is critical to ensure the highest level of patient care possible from your clinic.

 

Best Regards,

 

Bill

[mmhce]

Since the less than optimal scars were created under your direct supervision of this trainee, can you please tell us what you have learned from this and how you have changed your practice to prevent this from happening again?

 

The answer to the above question is critical to ensure the highest level of patient care possible from your clinic.

 

Bill is right.

 

Its like the currency of an economy.

 

IN GOD WE TRUST.

 

Confidence, faith and trust is ALL we got.